CMS/EIP Fiscal Report Center: 06
Services beginning 04/01/2025 ending 06/30/2025 Date of Report:07/19/2025 Page: 1
List order: No List
Payclass Filters:MED
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 342 1002.500000 37330.2000 37.2371
Subtotal (Total Children Is Unduplicated) 342 1002.500000 37330.2000 37.2371
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.000000 80.9800 80.9800
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 1.000000 80.9800 80.9800
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.500000 121.4700 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 3 3.500000 209.7200 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 3.000000 242.9400 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 7 8.500000 688.3300 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 7.000000 566.8600 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 6 7.500000 607.3500 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 3.000000 242.9400 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 3 3.500000 283.4300 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 4.000000 239.6800 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 7 7.500000 449.4000 59.9200
Subtotal (Total Children Is Unduplicated) 23 51.000000 3814.0800 74.7859
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 224 1727.000000 92895.0000 53.7898
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 50 300.000000 16146.0000 53.8200
OCCT-97530-OT SESSION BY LICENSED OT 2 15.000000 1219.8000 81.3200
OCCT-97530GT-OT SESSION BY LICENSED OT 1 1.000000 81.3200 81.3200
PHY-97110-PT SESSION BY LICENSED PT 3 31.000000 2520.9200 81.3200
PHY-97110GT-PT SESSION BY LICENSED PT 2 1.500000 121.9800 81.3200
PHY-97110HM-PT SESSION BY PT ASST 3 29.000000 1888.4800 65.1200
PHY-97110HMGT-PT SESSION BY PT ASST 2 12.000000 781.4400 65.1200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 15.000000 1219.8000 81.3200
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 7.500000 609.9000 81.3200
Subtotal (Total Children Is Unduplicated) 267 2139.000000 117484.6400 54.9250
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Total 3192.500000 158628.9200 49.6880
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Number of Children (Unduplicated) With at Least One Service 359
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Center 06
Flag Claims Units Chgs Paid
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R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
3736 3192.500000 158628.9200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3736 3192.500000 158628.9200 0.0000